A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Eliciting the gag reﬂex

Testing visual acuity

Observing for facial symmetry

Checking the pupillary response to light

Answer and Explanation

The Correct Answer is D

Choice A: Eliciting the gag reﬂex is a way to assess cranial nerve IX (glossopharyngeal) and X (vagus), which are responsible for the sensation and motor function of the pharynx and larynx.

Choice B: Testing visual acuity is a way to assess cranial nerve II (optic), which is responsible for the sense of vision.

Choice C: Observing for facial symmetry is a way to assess cranial nerve VII (facial), which is responsible for the motor function of the facial muscles and the sensation of taste.

Choice D: Checking the pupillary response to light is a way to assess cranial nerve III (oculomotor), which is responsible for the motor function of most of the eye muscles, including those that control pupil size and lens shape.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because magnesium 2.5 mEq/L is a normal value and does not indicate an increased risk of AKI. Magnesium is an electrolyte that plays a role in muscle and nerve function, blood pressure regulation, and energy production. The normal range for magnesium is 1.5 to 2.5 mEq/L.

Choice B Reason: This is incorrect because serum osmolality 290 mOsm/kg H2O is a normal value and does not indicate an increased risk of AKI. Serum osmolality is a measure of the concentration of solutes in the blood, such as sodium, glucose, and urea. The normal range for serum osmolality is 275 to 295 mOsm/kg H2O.

Choice C Reason: This is incorrect because blood urea nitrogen (BUN) 20 mg/dL is a normal value and does not indicate an increased risk of AKI. BUN is a measure of the amount of urea, a waste product of protein metabolism, in the blood. The normal range for BUN is 7 to 20 mg/dL.

Choice D Reason: This is correct because serum creatinine 1.8 mg/dL is an elevated value and indicates an increased risk of AKI. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. The normal range for serum creatinine is 0.6 to 1.2 mg/dL for women and 0.7 to 1.3 mg/dL for men. An increase in serum creatinine indicates a decrease in kidney function and glomerular filtration rate (GFR).

Correct Answer is ["125"]

Explanation

Step 1: Determine the total time required to infuse 40 mEq at a rate of 10 mEq/hr.

40 mEq ÷ 10 mEq/hr = 4 hours

Result: 4 hours

Step 2: Determine the infusion rate in mL/hr.

500 mL ÷ 4 hours = 125 mL/hr

Result: 125 mL/hr

The nurse should set the IV pump to deliver 125 mL/hr.

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A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings should the nurse identify as indicating an increased risk of AKI?

Correct Answer is D

Explanation

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["125"]

Explanation

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A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?